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ICD-10-CM S72.421S, Displaced fracture of lateral condyle of right femur, sequela | No Prior Auth

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`S72.421S`, Displaced fracture of lateral condyle of right femur, sequela

ICD-10-CM

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

For knee orthoses with adjustable knee joints or prefabricated Swedish type (HCPCS L1832, L1833, L1850) the medical record must document a physical examination of the affected knee(s) including the joint laxity test(s) performed and a description of exam findings that support objective joint laxity.
For single or double upright, adjustable flexion/extension knee orthoses with medial-lateral and rotation control (HCPCS L1843, L1844, L1845, L1846, L1851, L1852) used for ambulatory beneficiaries with knee instability, medical records must document ambulatory status and a physical exam of the affected knee(s) including joint laxity test(s) performed and description of findings supporting objective joint laxity.

For the same single/double upright orthoses (L1843, L1844, L1845, L1846, L1851, L1852) when used to manage pain affecting mobility/function due to medial or lateral tibiofemoral osteoarthritis, records must include ambulatory status; pain symptoms or mobility/functional reduction; physical exam of the affected knee(s); an imaging report describing arthritic changes consistent with medial/lateral tibiofemoral osteoarthritis; and the beneficiary's willingness to use the orthosis.

Supplier must include the treating diagnosis code(s) on the claim line for HCPCS L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, and L1860.

For custom-fabricated orthoses the supplier's records must document the medical necessity of a custom device rather than a prefabricated orthosis, and this documentation must be available upon request.

Suppliers must provide the product specified by the treating practitioner, ensure the practitioner's medical record justifies the product type (prefab versus custom), bill only the HCPCS code that accurately reflects the orthosis and fitting level, and maintain detailed supplier documentation that justifies the code selected.

Key Coverage Criteria

A knee orthosis is covered when it is a rigid or semi-rigid device used to support a weak or deformed knee or to restrict or eliminate motion in a diseased or injured knee and the device meets the reasonable and necessary requirements of the related Local Coverage Determination and all statutory/regulatory requirements.
Both off-the-shelf (OTS) and custom-fit knee orthoses are treated as prefabricated braces for coding and may be covered provided the coding accurately reflects whether only minimal self-adjustment was required at final fitting per 42 CFR §414.402.
If the orthosis is provided prior to an inpatient hospital admission or Part A SNF stay and the medical necessity begins during that inpatient stay, payment is included in the hospital or SNF payment (do not submit claim to the DME MAC).
An orthosis provided within two days prior to discharge and not needed for inpatient treatment but intended for home use is eligible for DME MAC coverage if medically necessary after discharge.
Occupational therapy is covered for patients with migraine (G43.xx) who require training to reduce pain during basic and instrumental activities of daily living, typically completed in 3–4 sessions.
Electrical stimulation (attended CPT 97032 or unattended HCPCS G0283) may be covered as part of a therapy plan of care to improve function when the nerve supply to the muscle is intact and atrophy is due to non-neurological disuse (e.g., post-casting, splinting, soft-tissue scarring).

9 Active Policies

A57064, Billing and Coding: Duplex Scan of Lower Extremity Arteries

J9

A53057, Billing and Coding: Home Health Occupational Therapy

A53058, Billing and Coding: Home Health Physical Therapy

A53064, Billing and Coding: Outpatient Occupational Therapy

A53065, Billing and Coding: Outpatient Physical Therapy

A56777, Billing and Coding: Total Joint Arthroplasty

A57311, Billing and Coding: Physical Therapy - Home Health

A52465, Knee Orthoses - Policy Article

A57685, Billing and Coding: Total Knee Arthroplasty

Related Codes

S72.441S(9 policies)S72.452S(9 policies)S72.431S(9 policies)S72.434S(9 policies)S72.444S(9 policies)S72.451S(9 policies)S72.424S(9 policies)S72.454S(9 policies)

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